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Admission note
An admission note (often called a "history and physical") is part of a medical record that documents the patient's status, reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
==Purpose==
Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record. Medical students often develop their clinical reasoning skills by writing admission notes. The traditional, rational definition of being admitted usually involves spending an overnight in the hospital. This definition is sometimes stretched in the U.S. medical billing industry, where hospital corporations may blur the definitions of "admission" and "observation" because of reimbursement rules under which healthcare payors pay less for the care if an "admission" was involved.
抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』
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